W43 Growing Pains 2: Accountable Program Development, Implementation and Operation' Dogwood Room

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W-43 Growing Pains 2 Accountable
Program Development, Implementation and
Operation.Dogwood Room
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Managing Behavioral Health Programs with less
dollars, greater regulatory control and increased
consumer demands.
The Challenge.....
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Why did the model for delivering behavioral
services change?
v Federal Staffing Grants in the 60s and 70s to
led to exponential cost increases v Cost report
rate setting went to accountable fee for service
payment provisions. v A transition from a
do-good approach of service delivery to an
externally imposed mandate for best practice and
cost effective treatment.
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As an agency Executive, how do you deal with
these pressures?

• 1. Design and implement clinical services that
  focus on consumers, market demand, service costs,
  and revenue/pricing.

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As an agency Executive, how do you deal with
these pressures?

• 2. Implement well designed information technology
  and record content for documenting and evaluating
  clinical efficacy and productivity.

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As an agency Executive, how do you deal with
these pressures?

• 3. Compliance with government and accreditation
  professional standards and regulations, in a best
  practices model that supports consumer needs and
  choice.

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As an agency Executive, how do you deal with
these pressures?

• 4. Strategically plan for changes in the
  marketplace by incorporating funding trends and,
  serving clients at a lower cost per incident of
  illness through program modifications and new
  clinical pathways.

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Quality is in the eye of the beholder!
Defining Quality.....
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Elements of Quality
Consumers
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Elements of Quality
Third Party Payors
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Elements of Quality
Practitioners
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Workshop Topics

• Presenters
• Credentialing
• EHR Implementation
• Attendees
• ?
• ?

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Credentialing

• Properly vet practitioners
• Verification of credentials at primary source
• Documentation of review process

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Credentialing

• Why?
• Increase quality service
• Increase credibility with licensing, MCOs,
  private payers
• Reduce risk of legal issues, licensing issues or
  damage to reputation

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Credentialing

• Follow standards even if you are not being
  accredited (NCQA, JCAHO)
• Provides structure
• Be familiar with rules of specific payors

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Credentialing

• Sources.
• Verify Pennsylvania Licenses of Psychologists,
  LSWs LCSWs, MDs and identify if there are
  sanctions against the license at
  www.dos.state.pa.us/dos/site/default.asp
• Database can be searched by name or license
  number.
• Verify that the Practitioner is not suspended,
  excluded or precluded from participating in the
  PA Medical Assistance Program at
  http//www.dpw.state.pa.us/Business/FraudAbuse/003
  673510.aspx
• Database is searchable by name.

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Credentialing

• Sources
• Office of Inspector General (OIG) List of
  Excluded Individuals and Entities (LEIE). Verify
  that the Practitioner is not suspended, excluded
  or precluded from participating in the Medicare
  or Medicaid Program. This list is more
  comprehensive than the PA List.
  https//oig.hhsc.state.tx.us/OIG_home.aspx
• Identify malpractice suits, loss of privileges,
  in any state. The NPDB facilitates a
  comprehensive review of the professional
  credentials of practitioners. The NPDB collects
  and disseminates reports on medical malpractice
  payments, adverse license actions, adverse
  clinical privileges, adverse professional society
  membership actions, and exclusions from
  Medicare/Medicaid.
• http//www.npdb-hipdb.hrsa.gov/pubs/gb/NPDB_Guide
  book_Chapter_B.pdf

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Credentialing

• National Practitioner Data Bank (NPDB)
• Established under Title IV of Public Law 99-660,
  the Health Care Quality Improvement Act of 1986.
• Information clearinghouse to collect and release
  information related to the
• professional competence and conduct of
  healthcare practitioners.

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Credentialing

• NPDB - Who Reports?
• Medical malpractice payers
• State Licensing Boards
• Hospitals and other health care entities
• Professional societies with formal peer review
• HHS Office of Inspector General
• US Drug Enforcement Administration
• State Agencies
• Health Plans

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EHR Implementation

• Streamline Clinical Record
• Link Forms Data
• Documentation Compliance
• Electronic Audits
• Staff Access to Real Time Data